| NPI | 1366735508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301048912) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD037954E) |
| Enumeration Date | 2011-05-20 |
| Last Update Date | 2011-05-20 |