| NPI | 1710373816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 86612) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 295164) |
| Enumeration Date | 2015-04-15 |
| Last Update Date | 2022-12-15 |