| NPI | 1851704589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 19155) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL ME141853) |
| 208D00000X General Practice (Licence: NY 316085) | |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2024-02-21 |