| NPI | 1053500223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WA MD0019545) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD0019545) |
| Enumeration Date | 2007-10-23 |
| Last Update Date | 2016-11-04 |