| NPI | 1629020326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102207660) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 04666) |
| 207Q00000X Family Medicine (Licence: WV 1939) | |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2024-04-30 |