| NPI | 1609865823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD460346) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35050904) |
| 207Q00000X Family Medicine (Licence: WI 65395) | |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2017-05-04 |