| NPI | 1124026117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: FL ACN631) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15516) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2025-11-12 |