| NPI | 1215290382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME113538) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2026-09-28 |