| NPI | 1770789125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 6242) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NM MD2014-0014) |
| Enumeration Date | 2007-06-22 |
| Last Update Date | 2018-07-12 |