| NPI | 1790179331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: IA 05241) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OR 172103) |
| Enumeration Date | 2015-03-21 |
| Last Update Date | 2021-05-24 |