| NPI | 1013118157 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042-0011459) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 77229) |
| 261QU0200X Clinic/Center, Urgent Care | |
| Enumeration Date | 2007-05-29 |
| Last Update Date | 2013-09-27 |