| NPI | 1366550279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 12700) |
| Additional Taxonomies | 208600000X Surgery (Licence: WV 12700) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2011-02-14 |