| NPI | 1063774149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS15833) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1152) |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2019-08-06 |