| NPI | 1306133210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS12575) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R-9308) |
| 207Q00000X Family Medicine (Licence: IA 4347) | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2019-12-17 |