| NPI | 1104136936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME129320) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 20121) |
| Enumeration Date | 2010-10-14 |
| Last Update Date | 2021-09-02 |