| NPI | 1972509107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 01934) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 54416) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2014-12-04 |