| NPI | 1891712592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 95-01458) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD192071) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2020-02-11 |