| NPI | 1053642819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WV 24177) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: VA 0101247818) |
| 282N00000X General Acute Care Hospital (Licence: 131740114) | |
| Enumeration Date | 2010-01-19 |
| Last Update Date | 2011-10-15 |