| NPI | 1164538674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 3861) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34008621) |
| 207Q00000X Family Medicine (Licence: MI 5101016678) | |
| Enumeration Date | 2006-08-21 |
| Last Update Date | 2012-04-18 |