| NPI | 1376564153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042-0015003) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX L8066) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2021-01-13 |