| NPI | 1053673509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO 0066781) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 53997) |
| Enumeration Date | 2012-06-11 |
| Last Update Date | 2021-11-15 |