| NPI | 1063815496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61223274) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MD D0032919) |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2022-09-15 |