| NPI | 1659631943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QG0300X Family Medicine, Geriatric Medicine (Licence: CT 50823) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 273862) |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: NY 268166) | |
| Enumeration Date | 2012-05-21 |
| Last Update Date | 2026-05-29 |