| NPI | 1588762702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 126973) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 12697) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2012-01-10 |