| NPI | 1750724621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 49272) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME125677) |
| Enumeration Date | 2013-04-10 |
| Last Update Date | 2020-03-14 |