| NPI | 1942294129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102201411) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 3173) |
| 207Q00000X Family Medicine (Licence: IA 3479) | |
| Enumeration Date | 2005-09-02 |
| Last Update Date | 2021-03-19 |