| NPI | 1124016134 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 45560) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 32895-020) |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2019-01-09 |