| NPI | 1164521670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD00025394) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NV 11269) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2019-07-16 |