| NPI | 1619928462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 0420007260) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 56005) |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2023-02-20 |