| NPI | 1225018104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 37206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 20454) |
| 207Q00000X Family Medicine (Licence: FL ME139866) | |
| Enumeration Date | 2006-01-18 |
| Last Update Date | 2019-05-31 |