| NPI | 1790040756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 39062) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 075157) |
| Enumeration Date | 2012-07-05 |
| Last Update Date | 2016-05-17 |