| NPI | 1982340816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61632615) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MRM-2144) |
| Enumeration Date | 2022-05-12 |
| Last Update Date | 2026-01-07 |