| NPI | 1104971589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 249805) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101243624) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2011-11-23 |