| NPI | 1700060092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2010-00567) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 16949) |
| 207Q00000X Family Medicine (Licence: VA 0101244562) | |
| Enumeration Date | 2007-12-21 |
| Last Update Date | 2011-12-06 |