| NPI | 1063772275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 71092-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA MD-41706) |
| Enumeration Date | 2012-05-22 |
| Last Update Date | 2021-01-19 |