| NPI | 1366496804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ME EC201008) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 011016-1) |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2021-03-11 |