| NPI | 1942612148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME128876) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN19935) |
| Enumeration Date | 2014-05-22 |
| Last Update Date | 2026-05-29 |