| NPI | 1710086236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: NC 96-00132) |
| Additional Taxonomies | 207V00000X Obstetrics & Gynecology (Licence: NC 9600132) |
| 208D00000X General Practice (Licence: NC 9600132) | |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2022-11-30 |