| NPI | 1104111566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A144136) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: CO 11-157) |
| Enumeration Date | 2011-06-14 |
| Last Update Date | 2023-03-07 |