| NPI | 1972940120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: AZ 006793) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA OP60645620) |
| Enumeration Date | 2013-05-29 |
| Last Update Date | 2026-04-28 |