| NPI | 1972642130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD00047144) |
| Additional Taxonomies | 208D00000X General Practice (Licence: AL MD27745) |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2012-12-20 |