| NPI | 1962630152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60411555) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MR-1056) |
| Enumeration Date | 2009-06-25 |
| Last Update Date | 2023-04-12 |