| NPI | 1609825553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101222102) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VA 0101222102) |
| Enumeration Date | 2006-05-09 |
| Last Update Date | 2017-07-07 |