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 |