| NPI | 1275984965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0116029433) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 32110201) |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2023-10-04 |