| NPI | 1720433451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME146526) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WV 29216) |
| Enumeration Date | 2016-05-02 |
| Last Update Date | 2026-05-22 |