| NPI | 1619953304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2003005729) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 2003005729) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2022-07-21 |