| NPI | 1205217742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101262896) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116028334) |
| Enumeration Date | 2015-06-10 |
| Last Update Date | 2021-06-01 |