| NPI | 1588789150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 44546) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 29988) |
| Enumeration Date | 2007-03-20 |
| Last Update Date | 2022-07-21 |