| NPI | 1134734130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS T4773) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY P105708) |
| Enumeration Date | 2020-09-15 |
| Last Update Date | 2022-07-02 |