| NPI | 1174554729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO176952) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 20A 6323) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2020-09-03 |