| NPI | 1790803443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0000X Family Medicine, Adolescent Medicine (Licence: WA 1122) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA 1122) |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2019-03-01 |