| NPI | 1508855917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID M-17332) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NM 80-158) |
| 208D00000X General Practice (Licence: NM 80-158) | |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2023-11-30 |