| NPI | 1952404170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NC 200601213) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 200601213) |
| 207Q00000X Family Medicine (Licence: WI 48660020) | |
| Enumeration Date | 2006-09-06 |
| Last Update Date | 2012-01-04 |