| NPI | 1942219803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 7156A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 43517) |
| Enumeration Date | 2006-08-07 |
| Last Update Date | 2022-10-31 |