| NPI | 1194162552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 290308) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS018120) |
| Enumeration Date | 2013-05-25 |
| Last Update Date | 2020-11-25 |