| NPI | 1508129727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2020-0002) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD459482) |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2020-01-22 |