| NPI | 1023325362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR 180720) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 19719) |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2021-06-15 |