| NPI | 1790040251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101026507) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101026507) |
| Enumeration Date | 2012-07-11 |
| Last Update Date | 2026-06-08 |