| NPI | 1679131866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME169822) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT217375) |
| Enumeration Date | 2019-06-03 |
| Last Update Date | 2025-12-05 |