| NPI | 1780919829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID MRM-1734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2119) |
| Enumeration Date | 2009-10-07 |
| Last Update Date | 2025-01-29 |