| NPI | 1821203019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2014-02496) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 13865) |
| Enumeration Date | 2007-05-11 |
| Last Update Date | 2016-12-06 |