| NPI | 1104836022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2014-02080) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME142535) |
| 207Q00000X Family Medicine (Licence: SC 18832) | |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2023-12-04 |