| NPI | 1053604868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 40505) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R-9179) |
| Enumeration Date | 2011-05-26 |
| Last Update Date | 2018-06-01 |