| NPI | 1780958058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 53644) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CT 53644) |
| 208D00000X General Practice (Licence: MI 4301086842) | |
| 208D00000X General Practice (Licence: CT 53644) | |
| Enumeration Date | 2012-03-02 |
| Last Update Date | 2023-03-24 |