| NPI | 1790818607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME107394) |
| Additional Taxonomies | 174400000X Specialist (Licence: PR 16113) |
| 207Q00000X Family Medicine (Licence: MO 2007034514) | |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2021-03-15 |