| NPI | 1730616079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME162311) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101269298) |
| Enumeration Date | 2017-05-17 |
| Last Update Date | 2023-09-08 |