| NPI | 1104246644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 19958) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL TPME4365) |
| 208D00000X General Practice (Licence: GA 91563) | |
| 208D00000X General Practice (Licence: TX U1112) | |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2023-12-17 |