| NPI | 1982055521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61056226) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 72098-20) |
| 207Q00000X Family Medicine (Licence: MI 4301110252) | |
| 207Q00000X Family Medicine (Licence: OR MD198278) | |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2020-10-01 |