| NPI | 1992384671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 14230691-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 005994) |
| Enumeration Date | 2021-04-07 |
| Last Update Date | 2025-11-11 |