| NPI | 1508527946 |
|---|---|
| Professional Name | NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY P113301) |
| Enumeration Date | 2022-01-07 |
| Last Update Date | 2022-01-07 |