| NPI | 1114465234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 53538) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY TP934) |
| Enumeration Date | 2017-02-09 |
| Last Update Date | 2020-07-27 |