| NPI | 1780038026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-76439) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: WV ED0596) |
| 207Q00000X Family Medicine (Licence: WV WVEDU) | |
| 207Q00000X Family Medicine (Licence: WV 3324) | |
| Enumeration Date | 2016-04-22 |
| Last Update Date | 2024-04-04 |