| NPI | 1356572101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 8932A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NV SL0644) |
| Enumeration Date | 2009-07-28 |
| Last Update Date | 2015-06-08 |