| NPI | 1255307047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA 390200000X) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD60043267) |
| Enumeration Date | 2006-02-23 |
| Last Update Date | 2021-06-03 |