| NPI | 1154662773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA 20A15183) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102207225) |
| 207Q00000X Family Medicine (Licence: NY 281926-01) | |
| Enumeration Date | 2013-03-06 |
| Last Update Date | 2023-05-31 |