| NPI | 1144959917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty (Licence: NY P115323) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX W2340) |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2026-03-12 |