| NPI | 1053572347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 72265) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: GA 72265) | |
| 208D00000X General Practice (Licence: VA 0101249751) | |
| Enumeration Date | 2008-06-19 |
| Last Update Date | 2014-07-18 |