| NPI | 1891861241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 56134) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301060737) |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2012-08-27 |