| NPI | 1215931902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME125779) |
| Additional Taxonomies | 174400000X Specialist (Licence: TX H2483) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2020-12-09 |