| NPI | 1629462502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: LA 306506) |
| Additional Taxonomies | 208D00000X General Practice (Licence: LA 306506) |
| Enumeration Date | 2015-03-27 |
| Last Update Date | 2020-01-15 |