| NPI | 1568434520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 34610) |
| Additional Taxonomies | 261QR1300X Clinic/Center, Rural Health |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2011-10-13 |