| NPI | 1568842797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301501292) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TPME3888) |
| 207Q00000X Family Medicine (Licence: PA MT209323) | |
| Enumeration Date | 2015-06-03 |
| Last Update Date | 2023-06-16 |