| NPI | 1053379735 |
|---|---|
| Professional Name | N/A N/A |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 112493) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 71548) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2021-10-22 |