| NPI | 1104886928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200800345) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 02613) |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2018-01-25 |