| NPI | 1902192503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2014-01370) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 248568) |
| Enumeration Date | 2011-06-22 |
| Last Update Date | 2021-03-31 |