| NPI | 1770903742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 0096-00110) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101044914) |
| Enumeration Date | 2014-04-17 |
| Last Update Date | 2014-04-17 |