| NPI | 1104236918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL MD.36392) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME129631) |
| 207Q00000X Family Medicine (Licence: FL TRN19855) | |
| Enumeration Date | 2014-05-01 |
| Last Update Date | 2021-02-25 |