| NPI | 1720077159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME123914) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 54845) |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2020-09-02 |