| NPI | 1639100191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200801162) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME111950) |
| 207Q00000X Family Medicine (Licence: GA 85057) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2020-09-03 |