| NPI | 1043573595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60490088) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA ML60293615) |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2015-07-03 |