| NPI | 1801980602 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 53511-020) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301078158) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2011-12-12 |