| NPI | 1700173200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS016855) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT013956) |
| Enumeration Date | 2011-07-05 |
| Last Update Date | 2014-10-04 |