| NPI | 1174769939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 66873) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 105193) |
| 207Q00000X Family Medicine (Licence: PA MT192598) | |
| Enumeration Date | 2008-12-29 |
| Last Update Date | 2024-12-02 |