| NPI | 1902470305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-02345) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014994) |
| Enumeration Date | 2021-05-19 |
| Last Update Date | 2024-08-19 |