| NPI | 1740690296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 55120) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 042.0014614) |
| Enumeration Date | 2014-05-06 |
| Last Update Date | 2020-08-29 |