| NPI | 1104082742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 73389-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 0049276) |
| 207Q00000X Family Medicine (Licence: OK 25807) | |
| Enumeration Date | 2008-08-04 |
| Last Update Date | 2021-11-22 |