| NPI | 1558365171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 696) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102050099) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2016-01-14 |