| NPI | 1558372680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 0093-00036) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN MD0000024476) |
| 207Q00000X Family Medicine (Licence: GA 036644) | |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2016-02-01 |