| NPI | 1972793354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME104086) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 245431) |
| Enumeration Date | 2007-07-31 |
| Last Update Date | 2018-04-02 |