| NPI | 1679241061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 331820) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT224532) |
| Enumeration Date | 2021-09-01 |
| Last Update Date | 2024-10-17 |