| NPI | 1912520792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 57502) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.148866) |
| 207Q00000X Family Medicine (Licence: PA MT220599) | |
| Enumeration Date | 2020-05-27 |
| Last Update Date | 2024-05-09 |