| NPI | 1790090611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60450926) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35121298) |
| Enumeration Date | 2010-08-16 |
| Last Update Date | 2020-10-14 |