| NPI | 1790843092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 14008R) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 770482) |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2023-03-07 |