| NPI | 1215929997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 19661) |
| Additional Taxonomies | 261QR1300X Clinic/Center, Rural Health (Licence: KY 19661) |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2016-06-01 |