| NPI | 1902829708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME0045287) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: FL ME0045287) |
| 207QD0401X (Licence: FL ME0045287) | |
| 208000000X Pediatrics (Licence: FL ME0045287) | |
| 2083B0002X Preventive Medicine, Obesity Medicine (Licence: FL ME0045287) | |
| 2080A0000X Pediatrics, Adolescent Medicine (Licence: FL ME0045287) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2026-03-17 |