| NPI | 1639284300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 238644) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 22648) |
| 261QC1500X Clinic/Center, Community Health (Licence: MA 238644) | |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2014-03-03 |