| NPI | 1053804997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL TRN27047) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME143495) |
| Enumeration Date | 2018-06-13 |
| Last Update Date | 2021-09-10 |