| NPI | 1710961586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA MD200094) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME 90786) |
| Enumeration Date | 2005-12-05 |
| Last Update Date | 2017-03-13 |