| NPI | 1104230929 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NJ 25MA11045400) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116026870) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2021-05-14 |