| NPI | 1184626277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME132532) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 00025470) |
| 207Q00000X Family Medicine (Licence: WI 16-320) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2020-04-17 |