| NPI | 1366530586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 02454) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN DO0000001103) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2007-07-08 |