| NPI | 1376886614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME142787) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 64764-20) |
| Enumeration Date | 2013-04-05 |
| Last Update Date | 2023-05-23 |