| NPI | 1619199056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 201501806) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 67508) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2021-03-12 |