| NPI | 1790030013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: KY 04719) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: VA 0102203664) |
| Enumeration Date | 2012-07-24 |
| Last Update Date | 2020-06-24 |