| NPI | 1770628471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AR E6231) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: TN AJ1165667-075) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2009-09-25 |