| NPI | 1609934975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 035655) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 205086 1) |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2008-05-02 |