| NPI | 1528050424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 201501224) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301054732) |
| Enumeration Date | 2005-08-17 |
| Last Update Date | 2016-01-11 |