| NPI | 1790705069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: CA A031828) |
| Additional Taxonomies | 208600000X Surgery (Licence: CA A31828) |
| 207Q00000X Family Medicine (Licence: CA A31828) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2016-09-30 |