| NPI | 1104113976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA A14153) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 272621) |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2020-08-03 |