| NPI | 1538456280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60535961) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301099120) |
| Enumeration Date | 2011-07-01 |
| Last Update Date | 2020-09-11 |