| NPI | 1053624296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2014-02114) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116022508) |
| 207Q00000X Family Medicine (Licence: CO DR.0071618) | |
| Enumeration Date | 2010-07-16 |
| Last Update Date | 2023-10-31 |