| NPI | 1013928985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL PA3622) |
| Additional Taxonomies | 261QC1500X Clinic/Center, Community Health (Licence: FL ACN296) |
| 261QC1500X Clinic/Center, Community Health (Licence: PR MD11514) | |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2011-06-10 |