| NPI | 1639564990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME173237) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 63535) |
| 207Q00000X Family Medicine (Licence: GA 080092) | |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2025-09-19 |