| NPI | 1891224697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2020023442) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 94-09271) |
| Enumeration Date | 2017-06-06 |
| Last Update Date | 2020-08-12 |