| NPI | 1053920504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 325117) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 77253-20) |
| Enumeration Date | 2020-07-29 |
| Last Update Date | 2023-08-03 |