| NPI | 1891354189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS021071) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT019140) |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2022-07-01 |