| NPI | 1629331772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 292161) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME121284) |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2022-07-11 |