| NPI | 1922369859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL TRN 17849) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA MD208003) |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2021-01-04 |