| NPI | 1992169205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO224733) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 2076) |
| Enumeration Date | 2016-04-12 |
| Last Update Date | 2025-09-03 |