| NPI | 1912296641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 258746) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: NY 258746) |
| Enumeration Date | 2011-04-04 |
| Last Update Date | 2012-09-24 |