| NPI | 1649705724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 304915) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CT 78147) |
| Enumeration Date | 2017-04-26 |
| Last Update Date | 2025-07-09 |