| NPI | 1811998743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 10201) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101023502) |
| Enumeration Date | 2005-08-02 |
| Last Update Date | 2007-07-08 |