| NPI | 1912654179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR 202202206NP) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OR 202202206NP) |
| Enumeration Date | 2022-03-08 |
| Last Update Date | 2022-07-18 |