| NPI | 1750375242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2004-01091) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 025958) |
| Enumeration Date | 2005-09-12 |
| Last Update Date | 2012-10-23 |