| NPI | 1063791317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 307615) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NJ 25MA09354300) |
| 207Q00000X Family Medicine (Licence: NY 275943) | |
| Enumeration Date | 2011-08-04 |
| Last Update Date | 2018-01-24 |