| NPI | 1538573571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: DE C2-0012700) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT016123) |
| Enumeration Date | 2014-06-18 |
| Last Update Date | 2018-09-14 |