| NPI | 1366591554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME50990) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 207Q00000x) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2010-11-10 |