| NPI | 1790182392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: OR DO202311) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 20A15368) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2023-04-17 |