| NPI | 1154588788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 254226) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 43384) |
| 207Q00000X Family Medicine (Licence: IN 01067509A) | |
| Enumeration Date | 2008-05-21 |
| Last Update Date | 2015-01-06 |