| NPI | 1104953249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA WA81714A) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA A81714) |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2010-11-04 |