| NPI | 1104832161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 38271) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IN 01057661A) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2022-07-21 |