| NPI | 1619196284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WV 19054) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OH 35080175) |
| 208D00000X General Practice (Licence: KY 35931) | |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2007-07-08 |