| NPI | 1558865618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 310941) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 310941) |
| Enumeration Date | 2018-03-22 |
| Last Update Date | 2023-07-07 |