| NPI | 1295978518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD20120647) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: NM MD20120647) |
| Enumeration Date | 2009-04-16 |
| Last Update Date | 2016-04-12 |