| NPI | 1063146157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 103203) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101284523) |
| Enumeration Date | 2022-07-13 |
| Last Update Date | 2025-07-22 |