| NPI | 1568509685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200200101) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME65017) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2020-07-14 |