| NPI | 1104347053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME138930) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN25062) |
| Enumeration Date | 2017-06-30 |
| Last Update Date | 2020-09-29 |