| NPI | 1942663695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 38696) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 79876) |
| 207Q00000X Family Medicine (Licence: FL ME163761) | |
| Enumeration Date | 2016-03-31 |
| Last Update Date | 2025-08-28 |