| NPI | 1255379749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 9191a) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL os9086) |
| Enumeration Date | 2006-06-04 |
| Last Update Date | 2014-07-07 |