| NPI | 1487629564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 21841) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA A91355) |
| 207Q00000X Family Medicine (Licence: PA MD417446) | |
| Enumeration Date | 2006-02-21 |
| Last Update Date | 2022-07-21 |