| NPI | 1073504130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101271881) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA 46474) |
| Enumeration Date | 2005-10-28 |
| Last Update Date | 2021-07-07 |