| NPI | 1205401551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 328745) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014929) |
| Enumeration Date | 2021-05-20 |
| Last Update Date | 2024-04-25 |