| NPI | 1861509135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: PA md012611E) |
| Additional Taxonomies | 311Z00000X Custodial Care Facility (Licence: PA md012611e) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2013-10-31 |