| NPI | 1104825926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2016-00121) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101049407) |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2022-06-23 |