| NPI | 1558459529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 40592) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: FL 40592) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2014-09-27 |