| NPI | 1811955362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME85807) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME85807) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2021-02-12 |