| NPI | 1174853659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME130768) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD039640L) |
| Enumeration Date | 2010-01-06 |
| Last Update Date | 2019-07-08 |