| NPI | 1205944071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME109563) |
| Additional Taxonomies | 174400000X Specialist (Licence: NY 240703) |
| 207Q00000X Family Medicine (Licence: NY 240703) | |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2021-11-23 |