| NPI | 1912903022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA 193400000x) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA os003987L) |
| Enumeration Date | 2005-06-23 |
| Last Update Date | 2016-09-16 |