| NPI | 1700883402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AR E0842) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 19680) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2011-12-14 |