| NPI | 1508855198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 16693) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MS 11192) |
| Enumeration Date | 2005-10-17 |
| Last Update Date | 2007-07-09 |