| NPI | 1164686622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 270324) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT204758) |
| Enumeration Date | 2008-07-14 |
| Last Update Date | 2023-04-24 |