| NPI | 1790760411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2018034961) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME92786) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2019-08-06 |