| NPI | 1013399419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61379551) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 68620) |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2024-01-29 |