| NPI | 1992058952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: ZZ 21290) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ZZ 21290) |
| 261QC1500X Clinic/Center, Community Health (Licence: ZZ 21290) | |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2020-03-11 |