| NPI | 1912692013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102210000) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL89933) |
| Enumeration Date | 2023-04-06 |
| Last Update Date | 2026-08-11 |