| NPI | 1942279013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 17521) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35-07-5727) |
| 207Q00000X Family Medicine (Licence: IL 036118847) | |
| 207Q00000X Family Medicine (Licence: WI 50755020) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2022-01-14 |