| NPI | 1558625863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME146621) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301100603) |
| 207Q00000X Family Medicine (Licence: WA MD60840812) | |
| 207Q00000X Family Medicine (Licence: MO 2015021634) | |
| Enumeration Date | 2012-07-02 |
| Last Update Date | 2021-02-10 |