| NPI | 1215066246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 1200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 1200) |
| Enumeration Date | 2007-03-05 |
| Last Update Date | 2007-07-08 |