| NPI | 1184152100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 333562) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 21323) |
| 207Q00000X Family Medicine (Licence: PA OS020831) | |
| Enumeration Date | 2017-06-03 |
| Last Update Date | 2026-07-10 |