| NPI | 1972669307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME101121) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 16302) |
| Enumeration Date | 2006-12-29 |
| Last Update Date | 2026-05-28 |