| NPI | 1659504413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY TP945) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 2009034796) |
| 208D00000X General Practice (Licence: NY 254349) | |
| 208D00000X General Practice (Licence: CT 048023) | |
| Enumeration Date | 2009-08-27 |
| Last Update Date | 2012-02-22 |