| NPI | 1295723112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2009-0562) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD0028340) |
| 207Q00000X Family Medicine (Licence: MT 11635) | |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2009-09-04 |