| NPI | 1528007176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS005625L) |
| Additional Taxonomies | 311Z00000X Custodial Care Facility (Licence: PA OS-005625L) |
| Enumeration Date | 2006-06-06 |
| Last Update Date | 2013-09-23 |