| NPI | 1942791553 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2022-02392) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL MD.42842) |
| 207Q00000X Family Medicine (Licence: SC MMD.88587) | |
| Enumeration Date | 2018-05-21 |
| Last Update Date | 2025-01-22 |