| NPI | 1063475465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 233406) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA 20A9952) |
| Enumeration Date | 2006-04-08 |
| Last Update Date | 2024-06-27 |