| NPI | 1386704856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 107758) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036-106551) |
| 207Q00000X Family Medicine (Licence: WI 42699) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2024-06-17 |