| NPI | 1457081572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS024727) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT022036) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2025-05-31 |