| NPI | 1902819311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 0420010549) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: VT 042-0010549) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2010-01-25 |