| NPI | 1104011386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 31574) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 59641) |
| Enumeration Date | 2007-09-11 |
| Last Update Date | 2015-06-05 |