| NPI | 1104031061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME125164) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 2010040907) |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2021-07-10 |