| NPI | 1508079088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: CA G64589) |
| Additional Taxonomies | 302R00000X Health Maintenance Organization (Licence: OR MD22737) |
| 302R00000X Health Maintenance Organization (Licence: WA MD00036973) | |
| Enumeration Date | 2007-05-08 |
| Last Update Date | 2007-07-08 |