| NPI | 1235441791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101272474) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD162200) |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2021-08-23 |