| NPI | 1891154860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL MS0112615) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT210110) |
| Enumeration Date | 2016-02-18 |
| Last Update Date | 2024-05-15 |