| NPI | 1760742084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2015008277) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NV SL0879) |
| Enumeration Date | 2012-05-21 |
| Last Update Date | 2020-09-01 |