| NPI | 1790775666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 16411) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 25292) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2026-06-25 |