| NPI | 1811458896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 93960) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 329391) |
| Enumeration Date | 2019-03-30 |
| Last Update Date | 2025-07-24 |