| NPI | 1972593705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2020-0323) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 35051) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2023-11-14 |