| NPI | 1104251263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD176762) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD.60674666) |
| Enumeration Date | 2013-09-09 |
| Last Update Date | 2021-02-16 |