| NPI | 1639330202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL TRN26147) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL CI355) |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2018-05-05 |