| NPI | 1912240698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NV 17489) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301102270) |
| Enumeration Date | 2013-04-01 |
| Last Update Date | 2017-11-18 |