| NPI | 1124453659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 257429) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME125545) |
| 207Q00000X Family Medicine (Licence: IL 036-140746) | |
| Enumeration Date | 2013-09-03 |
| Last Update Date | 2019-01-15 |