| NPI | 1598746679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 19201) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 40911) |
| Enumeration Date | 2005-11-07 |
| Last Update Date | 2012-03-28 |