| NPI | 1275536054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME142201) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 151546-1) |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2021-03-30 |