| NPI | 1306226121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD481798) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AK 201003) |
| 171000000X Military Health Care Provider | |
| 207Q00000X Family Medicine (Licence: IN 01078834A) | |
| 207Q00000X Family Medicine (Licence: NJ 25MA11691000) | |
| 208D00000X General Practice (Licence: IN 01078834A) | |
| Enumeration Date | 2015-06-06 |
| Last Update Date | 2025-02-04 |