| NPI | 1689642894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101265333) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301059911) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2019-09-05 |