| NPI | 1962932830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 96372) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2020-02623) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2023-10-20 |