| NPI | 1194930537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60096435) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301088517) |
| Enumeration Date | 2007-05-11 |
| Last Update Date | 2024-11-18 |