| NPI | 1558356543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 04-26419) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO MD 111595) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2022-02-10 |