| NPI | 1912303785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME142959) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 81861) |
| Enumeration Date | 2014-11-06 |
| Last Update Date | 2022-07-01 |