| NPI | 1407976491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: FL ACN581) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 11,242) |
| Enumeration Date | 2007-03-31 |
| Last Update Date | 2016-02-05 |