| NPI | 1407294408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 280685) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 133407) |
| Enumeration Date | 2013-06-12 |
| Last Update Date | 2015-06-25 |