| NPI | 1972502425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA G48556) |
| Additional Taxonomies | 314000000X Skilled Nursing Facility (Licence: CA G48556) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2012-08-29 |