| NPI | 1609867779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: KS 04-13573) |
| Additional Taxonomies | 261QH0100X Clinic/Center, Health Services (Licence: KS 04-13573) |
| Enumeration Date | 2005-10-28 |
| Last Update Date | 2015-12-29 |