| NPI | 1245217975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35034731) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 13693) |
| Enumeration Date | 2005-12-23 |
| Last Update Date | 2016-05-24 |