| NPI | 1902167232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS 12696) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL UO 3229) |
| Enumeration Date | 2012-06-04 |
| Last Update Date | 2024-01-04 |