| NPI | 1053309039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 65664) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 204887) |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2022-06-21 |