| NPI | 1053403634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 202K00000X (Licence: WA MD00038816) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD00038816) |
| Enumeration Date | 2006-09-29 |
| Last Update Date | 2019-01-15 |