| NPI | 1508120122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301110884) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125062119) |
| 207Q00000X Family Medicine (Licence: WI 64639) | |
| Enumeration Date | 2012-06-28 |
| Last Update Date | 2019-09-10 |