| NPI | 1689100935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 91454) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 301771) |
| Enumeration Date | 2017-05-05 |
| Last Update Date | 2025-11-07 |