| NPI | 1790135986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301110115) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4351030610) |
| Enumeration Date | 2016-06-17 |
| Last Update Date | 2023-11-03 |