| NPI | 1114154960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: KS 04-40613) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 27377) |
| 208D00000X General Practice (Licence: MO 2019014750) | |
| Enumeration Date | 2009-06-19 |
| Last Update Date | 2024-01-16 |