| NPI | 1376545939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 42565-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 216206) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2021-02-11 |