| NPI | 1851487417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 11392) |
| Additional Taxonomies | 314000000X Skilled Nursing Facility (Licence: AL 11392) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2012-11-06 |