| NPI | 1164566006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: VA 0101059337) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: NC 25686) |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2007-11-27 |