| NPI | 1962814855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2018-0106) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 0058723) |
| Enumeration Date | 2014-05-27 |
| Last Update Date | 2018-11-14 |