| NPI | 1316932866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 8017616-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ R1743) |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: UT 2014605) | |
| Enumeration Date | 2005-09-12 |
| Last Update Date | 2019-10-11 |