| NPI | 1124026992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME150657) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301068650) |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2023-08-31 |