| NPI | 1962514653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 29835) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 1587058905) |
| 207Q00000X Family Medicine (Licence: MT 8346) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2007-07-08 |