| NPI | 1992873400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: VA 0102033582) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA va0102033582) |
| Enumeration Date | 2006-12-01 |
| Last Update Date | 2023-08-16 |