| NPI | 1881636785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2018-0896) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101230784) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2019-05-29 |