| NPI | 1619218567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60747016) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116025462) |
| Enumeration Date | 2013-03-01 |
| Last Update Date | 2020-12-03 |