| NPI | 1104314145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: DC MD210012151) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101279899) |
| Enumeration Date | 2018-04-25 |
| Last Update Date | 2023-11-09 |