| NPI | 1912115445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME135563) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 11522) |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2022-11-03 |