| NPI | 1861019010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 161732) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4351046729) |
| Enumeration Date | 2020-07-02 |
| Last Update Date | 2026-01-29 |