| NPI | 1306880026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042-0011895) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD172092) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: VT 0420011895) | |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2015-08-03 |