| NPI | 1306872494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 103230) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC NCIP103230) |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2011-06-02 |