| NPI | 1821730763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 61002) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 13510321-1205) |
| Enumeration Date | 2022-04-11 |
| Last Update Date | 2025-07-09 |