| NPI | 1235220773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO 48011) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101016019) |
| 207Q00000X Family Medicine (Licence: NC 2007-00332) | |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2014-07-21 |