| NPI | 1033191564 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MD D0071582)  | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD426900)  | 
| Enumeration Date | 2005-11-18 | 
| Last Update Date | 2022-02-23 |