| NPI | 1700867504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO11649) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 21023) |
| 207Q00000X Family Medicine (Licence: FL OS9056) | |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2007-07-08 |