| NPI | 1316104086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 2494051) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 2494051) |
| Enumeration Date | 2008-05-20 |
| Last Update Date | 2012-12-14 |