| NPI | 1104902659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD164138) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 3870A) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2020-09-30 |