| NPI | 1366736761 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0116026173) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102204067) |
| Enumeration Date | 2011-06-02 |
| Last Update Date | 2015-11-30 |