| NPI | 1063494631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME139388) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101235066) |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2019-03-05 |