| NPI | 1487749917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 3048) |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: PR 3048) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2007-07-08 |