| NPI | 1922005347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 4371-A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 181920-8905) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2019-06-13 |