| NPI | 1376779793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 0010-06961) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 664) |
| Enumeration Date | 2009-06-01 |
| Last Update Date | 2022-07-21 |