| NPI | 1063456028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME132750) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 14474) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2021-08-11 |