| NPI | 1053552455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: WI 66559-21) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 20A12811) |
| Enumeration Date | 2009-03-13 |
| Last Update Date | 2017-04-04 |