| NPI | 1376523795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: PA MD033225E) |
| Additional Taxonomies | 311Z00000X Custodial Care Facility (Licence: PA MD033225E) |
| Enumeration Date | 2006-01-20 |
| Last Update Date | 2026-05-21 |