| NPI | 1912401506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD211225) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 11393263-1205) |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2022-10-20 |