| NPI | 1972711851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: OH 35.130085) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL ME107505) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2025-06-11 |