| NPI | 1184621054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME137239) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 135753) |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: FL ME137239) | |
| Enumeration Date | 2005-07-06 |
| Last Update Date | 2019-08-22 |