| NPI | 1972113421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61665908) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2020017672) |
| 207Q00000X Family Medicine (Licence: MI 4351050073) | |
| Enumeration Date | 2020-08-08 |
| Last Update Date | 2025-07-10 |