| NPI | 1972036515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 345593) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: PA MD470650) |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2026-06-28 |