| NPI | 1700315272 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61059096) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 94-09210) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2021-04-07 |