| NPI | 1063410579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME143542) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2003002302) |
| Enumeration Date | 2005-07-08 |
| Last Update Date | 2026-03-12 |