| NPI | 1790755510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101258016) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD00034782) |
| Enumeration Date | 2006-01-24 |
| Last Update Date | 2020-03-27 |