| NPI | 1992748180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101264388) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 14161) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2022-01-18 |