| NPI | 1255491635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NH 20947) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD169675) |
| 207Q00000X Family Medicine (Licence: IA 36375) | |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2020-12-01 |