| NPI | 1639514532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 306028) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME128732) |
| 207Q00000X Family Medicine (Licence: SC 89229) | |
| Enumeration Date | 2013-05-06 |
| Last Update Date | 2025-09-02 |