| NPI | 1669831855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME140146) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 13801I) |
| Enumeration Date | 2016-02-16 |
| Last Update Date | 2021-01-21 |