| NPI | 1700102696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 8046565-1205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AK MEDS7754) |
| Enumeration Date | 2010-04-16 |
| Last Update Date | 2022-10-13 |