| NPI | 1700129475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61414100) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036.140995) |
| 207Q00000X Family Medicine (Licence: OH 35-132398) | |
| Enumeration Date | 2013-04-01 |
| Last Update Date | 2023-08-03 |