| NPI | 1962556951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101025209) |
| Additional Taxonomies | 171W00000X Contractor (Licence: VA 0101025209) |
| 261QM1101X Clinic/Center, Military and U.S. Coast Guard Ambulatory Procedure (Licence: VA 0101025209) | |
| 261QU0200X Clinic/Center, Urgent Care (Licence: VA 0101025209) | |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2011-12-15 |