| NPI | 1558363697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200501746) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SD SD5207) |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2008-12-09 |