| NPI | 1811349079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 64745) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301109372) |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2024-11-06 |