| NPI | 1104895747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 340004179) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ME LT16010) |
| Enumeration Date | 2006-03-16 |
| Last Update Date | 2016-05-13 |