| NPI | 1154545028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101241552) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT182383) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2022-01-29 |