| NPI | 1063797827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: AK 140816) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA A48661) |
| 208D00000X General Practice (Licence: ND 12175) | |
| Enumeration Date | 2011-10-12 |
| Last Update Date | 2019-05-14 |