| NPI | 1003312604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-127892) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 032.0134072) |
| 207Q00000X Family Medicine (Licence: NY 309431) | |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2023-09-07 |