| NPI | 1730176793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME122358) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 167827) |
| Enumeration Date | 2005-10-04 |
| Last Update Date | 2022-05-03 |