| NPI | 1588926620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2019012274) |
| Additional Taxonomies | 208D00000X General Practice (Licence: HI DOS-1551) |
| Enumeration Date | 2012-06-14 |
| Last Update Date | 2019-07-19 |