| NPI | 1346621059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 45154) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2015019270) |
| Enumeration Date | 2015-06-18 |
| Last Update Date | 2018-12-28 |