| NPI | 1629053111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101043218) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 39501) |
| 207Q00000X Family Medicine (Licence: CA G74883) | |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2023-03-07 |