| NPI | 1023248614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 39396) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 3130-850) |
| 207Q00000X Family Medicine (Licence: MN 55507) | |
| Enumeration Date | 2009-07-17 |
| Last Update Date | 2015-01-22 |