| NPI | 1124019880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 1473) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102202969) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2012-02-17 |