| NPI | 1124405691 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 25884) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 38401) |
| Enumeration Date | 2015-05-04 |
| Last Update Date | 2018-07-03 |