| NPI | 1356398739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM A-1601-11) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 02142) |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2015-11-16 |