| NPI | 1902198781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2015018628) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 60064-20) |
| Enumeration Date | 2011-05-11 |
| Last Update Date | 2021-02-04 |