| NPI | 1649762592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD490981) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2019047627) |
| Enumeration Date | 2018-06-05 |
| Last Update Date | 2025-08-22 |