| NPI | 1962517011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 27619) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 24245) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2021-11-18 |