| NPI | 1861139263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 35490) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 88140) |
| Enumeration Date | 2022-05-17 |
| Last Update Date | 2025-07-29 |