| NPI | 1750385340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 8022) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 1440) |
| 207Q00000X Family Medicine (Licence: AK 5911) | |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2010-10-26 |