| NPI | 1316697071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 4651) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 000) |
| Enumeration Date | 2022-03-25 |
| Last Update Date | 2025-07-08 |