| NPI | 1407105695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PA MD-059947-L) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WV 16697) |
| Enumeration Date | 2012-09-04 |
| Last Update Date | 2024-04-26 |