| NPI | 1770786550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101057390) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101057390) |
| Enumeration Date | 2007-06-07 |
| Last Update Date | 2012-05-01 |