| NPI | 1548642655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP61094020) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101021839) |
| Enumeration Date | 2015-06-25 |
| Last Update Date | 2021-03-04 |