| NPI | 1295766962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD 023790 E) |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: PA MD 023790 E) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2007-07-08 |