| NPI | 1154980464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 341052) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116032851) |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2026-08-25 |