| NPI | 1902010952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 05629R) |
| Additional Taxonomies | 174400000X Specialist (Licence: LA 05629R) |
| 208D00000X General Practice (Licence: LA 05629R) | |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2015-11-10 |