| NPI | 1104011618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 251400) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 40424) |
| Enumeration Date | 2007-09-07 |
| Last Update Date | 2021-01-20 |