| NPI | 1063617975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MD D71101) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD439290) |
| Enumeration Date | 2007-06-19 |
| Last Update Date | 2014-09-30 |