| NPI | 1164419602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NH 10346) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 273460) |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2020-09-10 |