| NPI | 1386919579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 11473) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1295) |
| 207Q00000X Family Medicine (Licence: IA DO-05237) | |
| Enumeration Date | 2012-03-20 |
| Last Update Date | 2022-04-29 |