| NPI | 1265454920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME95446) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 235653) |
| 207Q00000X Family Medicine (Licence: SC 23229) | |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2024-01-10 |