| NPI | 1285956987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 010369) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 2409) |
| Enumeration Date | 2010-02-22 |
| Last Update Date | 2010-02-22 |