| NPI | 1174786420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD440607) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NJ 0000000000) |
| Enumeration Date | 2008-07-08 |
| Last Update Date | 2012-03-07 |