| NPI | 1972918514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 289269) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CT 056952) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2018-08-08 |