| NPI | 1093008401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA MD205679) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: LA 205679) |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2022-04-27 |