| NPI | 1104099126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD031084E) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MD031084E) |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2020-11-17 |