| NPI | 1700885308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 1897) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 1897) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2007-09-27 |