| NPI | 1356960298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME167047) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4351047281) |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2025-07-17 |