| NPI | 1700066586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME81042) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: FL ME81042) |
| Enumeration Date | 2007-11-08 |
| Last Update Date | 2026-05-14 |