| NPI | 1619065190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: WV 22493) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 22493) |
| 207Q00000X Family Medicine (Licence: OH 35.088590) | |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2020-08-26 |