| NPI | 1568463925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR1300X Clinic/Center, Rural Health |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO R3C32) |
| 261Q00000X Clinic/Center | |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2013-08-14 |