| NPI | 1912523002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101027351) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5315239372) |
| Enumeration Date | 2020-06-24 |
| Last Update Date | 2023-03-18 |