| NPI | 1154717551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME155199) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35133230) |
| Enumeration Date | 2015-04-13 |
| Last Update Date | 2024-08-15 |