| NPI | 1619965258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 37677) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA GA53071) |
| Enumeration Date | 2005-10-07 |
| Last Update Date | 2007-07-08 |