| NPI | 1568030781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME165446) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 32260) |
| Enumeration Date | 2021-06-14 |
| Last Update Date | 2024-08-06 |