| NPI | 1205415395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS024064) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT020517) |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2024-07-29 |