| NPI | 1447456843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: OR MD06015) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: OR MD06015) |
| Enumeration Date | 2007-06-22 |
| Last Update Date | 2007-07-13 |