| NPI | 1679839252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS15193) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS017249) |
| Enumeration Date | 2012-04-08 |
| Last Update Date | 2021-11-22 |