| NPI | 1366442733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2012-02352) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 174873) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NY 174873) | |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2020-10-25 |