| NPI | 1124382130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2016-01326) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT015040) |
| Enumeration Date | 2012-06-25 |
| Last Update Date | 2021-04-14 |