| NPI | 1053743898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA 0SO21502) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 000000) |
| Enumeration Date | 2013-08-03 |
| Last Update Date | 2023-09-05 |