| NPI | 1114331964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-02643) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102204434) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2021-02-10 |