| NPI | 1609877489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: RI CMD06972) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX G7396) |
| 207Q00000X Family Medicine (Licence: MA 150111) | |
| Enumeration Date | 2005-08-03 |
| Last Update Date | 2014-12-02 |