| NPI | 1710244124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2003018093) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 04-23901) |
| Enumeration Date | 2012-04-23 |
| Last Update Date | 2012-04-23 |