| NPI | 1063500403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME131605) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND 9485) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2019-08-06 |