| NPI | 1063605723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60487350) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101247095) |
| Enumeration Date | 2007-08-24 |
| Last Update Date | 2021-01-18 |