| NPI | 1043209836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO DOR5B81) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO R5B81) |
| Enumeration Date | 2005-10-14 |
| Last Update Date | 2014-01-06 |