| NPI | 1588159990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5151014113) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT018842) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2019-07-02 |