| NPI | 1104855055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PA MD035816E) |
| Additional Taxonomies | 174400000X Specialist (Licence: PA MD035816E) |
| Enumeration Date | 2006-07-02 |
| Last Update Date | 2023-08-16 |