| NPI | 1568768455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 8611A) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NV 15455) |
| Enumeration Date | 2011-02-10 |
| Last Update Date | 2015-04-02 |