| NPI | 1104088384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: WI 15871-020) |
| Additional Taxonomies | 172V00000X Community Health Worker (Licence: WI 15871-020) |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2008-06-27 |