| NPI | 1518964873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 83970) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME0046524) |
| Enumeration Date | 2005-07-01 |
| Last Update Date | 2021-02-08 |