| NPI | 1063891380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60911931) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 9408598) |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2020-12-03 |