| NPI | 1982265161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 12951971-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT019600) |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2024-04-10 |