| NPI | 1720076011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: RI MD10880) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 214029) |
| Enumeration Date | 2005-10-11 |
| Last Update Date | 2012-01-13 |