| NPI | 1104081082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 75198) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 31545) |
| Enumeration Date | 2008-07-21 |
| Last Update Date | 2021-10-19 |