| NPI | 1619068848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD24521) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AK 5339) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2007-07-08 |