| NPI | 1912493560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 86395) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL61172) |
| 207Q00000X Family Medicine (Licence: VA 0101288533) | |
| Enumeration Date | 2018-07-06 |
| Last Update Date | 2026-02-12 |