| NPI | 1821518267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 71742-21) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT017738) |
| Enumeration Date | 2017-06-27 |
| Last Update Date | 2020-09-01 |