| NPI | 1003059874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 23667) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301093757) |
| 207Q00000X Family Medicine (Licence: FL 106324) | |
| Enumeration Date | 2009-04-09 |
| Last Update Date | 2018-10-31 |