| NPI | 1063400117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS0005530) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA OP00001040) |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2020-01-09 |