| NPI | 1902888357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 78392) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME42445) |
| 207Q00000X Family Medicine (Licence: SC 33164) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2020-09-10 |