| NPI | 1790729572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 34878) |
| Additional Taxonomies | 207QA0000X Family Medicine, Adolescent Medicine (Licence: KY 34878) |
| 207QA0505X Family Medicine, Adult Medicine (Licence: KY 34878) | |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: KY 34878) | |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2012-06-27 |