| NPI | 1336435049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60609109) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 276778) |
| Enumeration Date | 2011-06-21 |
| Last Update Date | 2017-12-13 |