| NPI | 1164491221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042-0012421) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CT 039959) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2012-07-24 |