| NPI | 1619438355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS19251) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 312146) |
| Enumeration Date | 2019-03-26 |
| Last Update Date | 2023-01-25 |