| NPI | 1013148857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL UO 3255) |
| Additional Taxonomies | 174400000X Specialist (Licence: NV SL0670) |
| Enumeration Date | 2009-07-28 |
| Last Update Date | 2012-06-28 |