| NPI | 1194086348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME121015) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN# 17725) |
| Enumeration Date | 2012-06-05 |
| Last Update Date | 2021-12-05 |