| NPI | 1104011444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: NM MD2008-0255) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NM MD 2008-0255) |
| Enumeration Date | 2007-09-10 |
| Last Update Date | 2018-06-19 |