| NPI | 1215063235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO153705) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS010387L) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2020-01-13 |