| NPI | 1245342765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101261879) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 21733) |
| 207Q00000X Family Medicine (Licence: OH 3584922) | |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: VA 0101261879) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2018-03-17 |