| NPI | 1548754583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 16197) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 05086) |
| Enumeration Date | 2018-06-21 |
| Last Update Date | 2022-10-04 |