| NPI | 1447573688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301404095) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: MI 4301404095) |
| Enumeration Date | 2010-03-02 |
| Last Update Date | 2010-03-02 |