| NPI | 1770572943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60454301) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 0420008304) |
| Enumeration Date | 2005-10-19 |
| Last Update Date | 2021-05-19 |