| NPI | 1962077198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA 61558784) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014880) |
| Enumeration Date | 2021-05-20 |
| Last Update Date | 2024-06-27 |