| NPI | 1114363306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102204760) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT015134) |
| 207Q00000X Family Medicine (Licence: PA OS017233) | |
| Enumeration Date | 2013-05-15 |
| Last Update Date | 2020-07-31 |