| NPI | 1902393994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101028074) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 75601) |
| Enumeration Date | 2018-04-16 |
| Last Update Date | 2024-06-05 |