| NPI | 1063755700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME170463) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 74070) |
| Enumeration Date | 2013-04-01 |
| Last Update Date | 2026-02-08 |