| NPI | 1669495867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 08953) |
| Additional Taxonomies | 261QP2300X Clinic/Center Primary Care (Licence: SC 89530) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2016-04-13 |