| NPI | 1801008552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD00015223) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AK 6721) |
| 207Q00000X Family Medicine (Licence: WI 55963-020) | |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2011-08-17 |