| NPI | 1972608297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60322685) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 24201) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2025-07-09 |