| NPI | 1982992475 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301099328) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301099328) |
| Enumeration Date | 2011-07-18 |
| Last Update Date | 2023-12-05 |