| NPI | 1962489195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME47243) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health (Licence: FL ME47243) |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2023-08-30 |