| NPI | 1366714099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: HI 9634) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA 00012095) |
| Enumeration Date | 2012-01-26 |
| Last Update Date | 2012-01-26 |