| NPI | 1780386664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A208332) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301514567) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2026-06-26 |