| NPI | 1376653543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101010542) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS006426L) |
| 207Q00000X Family Medicine (Licence: NJ 25MB05291500) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2007-07-08 |