| NPI | 1134859283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23577) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 210) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2024-07-01 |