| NPI | 1578591095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME125780) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 38511) |
| 207QA0000X Family Medicine Adolescent Medicine (Licence: KY 38511) | |
| 207QA0401X Family Medicine Addiction Medicine (Licence: KY 38511) | |
| 207QA0505X Family Medicine Adult Medicine (Licence: KY 38511) | |
| 207QG0300X Family Medicine Geriatric Medicine (Licence: KY 38511) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: KY 38511) | |
| 207VX0000X Obstetrics & Gynecology Obstetrics (Licence: KY 38511) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2016-02-03 |