| NPI | 1700110194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60411757) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AK 6225) |
| 207Q00000X Family Medicine (Licence: VA 0102202452) | |
| 207Q00000X Family Medicine (Licence: AK 7307) | |
| 207Q00000X Family Medicine (Licence: WV 2400) | |
| Enumeration Date | 2009-10-01 |
| Last Update Date | 2019-04-08 |