| NPI | 1679574453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 45768-021) |
| Additional Taxonomies | 208600000X Surgery (Licence: WI 45768-021) |
| Enumeration Date | 2005-08-03 |
| Last Update Date | 2014-10-24 |