| NPI | 1386930287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101257641) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT199021) |
| 207Q00000X Family Medicine (Licence: MD D0078580) | |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2016-02-20 |