| NPI | 1083870455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102202346) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS-014404) |
| Enumeration Date | 2008-08-05 |
| Last Update Date | 2021-03-30 |