| NPI | 1679903454 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 49798) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN17608) |
| 207Q00000X Family Medicine (Licence: FL ME118597) | |
| Enumeration Date | 2013-11-15 |
| Last Update Date | 2020-01-09 |