| NPI | 1316028947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AK 124117) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MT 11341) |
| 207Q00000X Family Medicine (Licence: CO 45117) | |
| 207Q00000X Family Medicine (Licence: WI 48498-020) | |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2020-10-03 |