| NPI | 1164950523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP61299466) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 20A17321) |
| Enumeration Date | 2017-05-30 |
| Last Update Date | 2023-04-25 |