| NPI | 1770077562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA R-12083) |
| Additional Taxonomies | 207V00000X Obstetrics & Gynecology (Licence: KY 94-09611) |
| Enumeration Date | 2018-06-15 |
| Last Update Date | 2022-06-30 |