| NPI | 1790205755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101265229) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116030268) |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2022-07-21 |