| NPI | 1417950270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 510100847) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 02533) |
| 207Q00000X Family Medicine (Licence: TN 1238) | |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2021-10-01 |