| NPI | 1902858707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 27640) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2006-01808) |
| 207Q00000X Family Medicine (Licence: FL ME80363) | |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2023-03-27 |