| NPI | 1811991607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ND 5224) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 29469) |
| 207Q00000X Family Medicine (Licence: AZ 20110) | |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2010-10-15 |