| NPI | 1174604706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2008 01744) |
| Additional Taxonomies | 2086S0122X Surgery, Plastic and Reconstructive Surgery (Licence: NC 2008-01744) |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2011-03-02 |