| NPI | 1962790519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME119544) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301099540) |
| Enumeration Date | 2011-07-18 |
| Last Update Date | 2014-08-19 |