| NPI | 1912261876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 125248) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 19093) |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2025-06-04 |