| NPI | 1043848260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA A204398) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX U4809) |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2026-08-07 |