| NPI | 1619047495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS11563) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS006688E) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2021-04-30 |