| NPI | 1780675876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME127949) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 225376) |
| 207Q00000X Family Medicine (Licence: CA A066341) | |
| 207Q00000X Family Medicine (Licence: NY 277732) | |
| Enumeration Date | 2005-10-29 |
| Last Update Date | 2024-02-20 |