| NPI | 1174964415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 296567) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CT 055086) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-07-15 |
| Last Update Date | 2021-10-19 |