| NPI | 1427413434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 302R00000X Health Maintenance Organization |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2015-12-17 |
| Last Update Date | 2015-12-17 |