| NPI | 1003995754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA g5288) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: CA G52888) |
| Enumeration Date | 2006-11-03 |
| Last Update Date | 2020-07-16 |