| NPI | 1003222563 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 05-40614) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2014021710) |
| Enumeration Date | 2014-07-06 |
| Last Update Date | 2019-06-10 |