| NPI | 1114900016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY ky38224) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036110727) |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2016-08-30 |