| NPI | 1144218652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 4903985 1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101007259) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2010-12-07 |