| NPI | 1104814946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200401306) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101009995) |
| Enumeration Date | 2005-10-06 |
| Last Update Date | 2013-02-20 |