| NPI | 1891058558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 10037A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116024836) |
| 207Q00000X Family Medicine (Licence: PA OS016968) | |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2016-03-07 |