| NPI | 1801404603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 81873) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R-12005) |
| Enumeration Date | 2020-07-17 |
| Last Update Date | 2025-08-13 |