| NPI | 1265464523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60565160) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 6355A) |
| 207Q00000X Family Medicine (Licence: MT 11200) | |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2015-08-25 |