| NPI | 1902834740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 34610) |
| Additional Taxonomies | 207QA0000X Family Medicine, Adolescent Medicine (Licence: KY 34610) |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: KY 34610) | |
| 207QA0505X Family Medicine, Adult Medicine (Licence: KY 34610) | |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: KY 34610) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: KY 34610) | |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2007-07-08 |