| NPI | 1164423596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME0036411) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101030483) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2008-05-19 |