| NPI | 1205935590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301401337) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 17095) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2009-09-25 |