| NPI | 1104833987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD179254) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 953130631205) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2016-08-18 |