| NPI | 1679568554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 30739) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 9900303) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2019-02-06 |