| NPI | 1801536065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 87750) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL87550) |
| Enumeration Date | 2022-03-29 |
| Last Update Date | 2026-08-31 |