| NPI | 1629139829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 13871) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35029763A) |
| 207Q00000X Family Medicine (Licence: FL 36019) | |
| 207Q00000X Family Medicine (Licence: AK 3676) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2007-07-09 |