| NPI | 1730325143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 7111227-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MRO-1496) |
| 111N00000X Chiropractor (Licence: UT 7111227-1202) | |
| Enumeration Date | 2009-01-07 |
| Last Update Date | 2018-05-10 |