| NPI | 1598147118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME129873) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 94574) |
| 207Q00000X Family Medicine (Licence: NC 2022-02592) | |
| Enumeration Date | 2015-06-19 |
| Last Update Date | 2024-07-15 |