| NPI | 1396044160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 110736) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY ASO76758539) |
| Enumeration Date | 2011-03-19 |
| Last Update Date | 2017-03-21 |