| NPI | 1912936212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: KY 21368) |
| Additional Taxonomies | 208D00000X General Practice (Licence: KY 21368) |
| Enumeration Date | 2006-07-01 |
| Last Update Date | 2013-06-20 |