| NPI | 1770555294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 92624) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 24768) |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2010-04-02 |