| NPI | 1184730772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 21088) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 45681-020) |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2007-07-08 |