| NPI | 1063418580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: FL ME88723) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: FL ME88723) |
| Enumeration Date | 2005-06-21 |
| Last Update Date | 2020-03-19 |