| NPI | 1912643909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4351049475) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5315232777) |
| Enumeration Date | 2022-05-11 |
| Last Update Date | 2022-05-11 |