| NPI | 1215929658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 211553) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NH 13074) |
| Enumeration Date | 2005-08-22 |
| Last Update Date | 2014-02-18 |