| NPI | 1891107991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME128999) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN20222) |
| Enumeration Date | 2014-05-22 |
| Last Update Date | 2018-02-06 |