| NPI | 1578210456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 315027) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 315027) |
| Enumeration Date | 2022-03-09 |
| Last Update Date | 2022-06-06 |