| NPI | 1295717759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 162396-1205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 25816) |
| 207Q00000X Family Medicine (Licence: WA md00028844) | |
| 207Q00000X Family Medicine (Licence: AK 4879) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2012-03-30 |