| NPI | 1215252549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-34400) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA MD.207223) |
| 207Q00000X Family Medicine (Licence: PA MD449905) | |
| Enumeration Date | 2010-03-30 |
| Last Update Date | 2014-08-13 |