| NPI | 1588042147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 93589) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 28408) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2022-10-31 |