| NPI | 1972692366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NC 200200150) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: NC 200200150) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2021-10-01 |