| NPI | 1104020288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9601785) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 10475) |
| 207Q00000X Family Medicine (Licence: SC 7509) | |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2013-02-28 |