| NPI | 1699123968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME141969) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT211126) |
| 207Q00000X Family Medicine (Licence: VA 0101285929) | |
| Enumeration Date | 2016-05-27 |
| Last Update Date | 2025-06-30 |