| NPI | 1972126530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME162106) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 77545-20) |
| Enumeration Date | 2020-05-18 |
| Last Update Date | 2025-10-31 |