| NPI | 1194250936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 13078588-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT019463) |
| Enumeration Date | 2017-05-01 |
| Last Update Date | 2023-05-01 |