| NPI | 1508891078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY TL2895) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 43917) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2015-02-26 |