| NPI | 1619332962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NV DO2173) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NV DO2173) |
| 207Q00000X Family Medicine (Licence: FL OS13738) | |
| Enumeration Date | 2015-12-30 |
| Last Update Date | 2017-08-04 |