| NPI | 1255380341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 11971) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 042-0010631) |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2026-01-13 |