| NPI | 1962439109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-01089) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 82176) |
| 207Q00000X Family Medicine (Licence: MO 2006025644) | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2024-08-26 |