| NPI | 1396740783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9700706) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME130601) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2021-05-26 |