| NPI | 1114746740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 17456-I) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 002079-P.A.) |
| Enumeration Date | 2024-10-09 |
| Last Update Date | 2025-08-15 |