| NPI | 1902245848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 51086) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY R3662) |
| Enumeration Date | 2013-06-24 |
| Last Update Date | 2021-03-31 |