| NPI | 1528266509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA MD.202162) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME 100237) |
| Enumeration Date | 2007-07-11 |
| Last Update Date | 2012-06-21 |