| NPI | 1861660649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208VP0000X (Licence: FL ME22595) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: FL 022595) |
| Enumeration Date | 2008-02-14 |
| Last Update Date | 2012-05-01 |