| NPI | 1104863471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WY 5383A) |
| Additional Taxonomies | 208D00000X General Practice (Licence: IA 1338) |
| 208D00000X General Practice (Licence: MO 31534) | |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2007-07-08 |