| NPI | 1871597385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 7354) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 8253) |
| Enumeration Date | 2005-06-13 |
| Last Update Date | 2014-06-30 |