| NPI | 1407875859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 101719) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: NC 101719) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2012-07-24 |