| NPI | 1659433712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 17200) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 17200) |
| 207ZP0102X Pathology, Anatomic Pathology & Clinical Pathology (Licence: NE 17200) | |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2013-03-18 |