| NPI | 1891058996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 295906) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 9709A) |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2019-03-07 |