| NPI | 1164696118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2088P0231X (Licence: FL ME117509) |
| Additional Taxonomies | 2088P0231X (Licence: TX Q1584) |
| 208D00000X General Practice (Licence: PR 18056) | |
| Enumeration Date | 2008-04-21 |
| Last Update Date | 2024-03-12 |