| NPI | 1154853406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101265763) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX S0716) |
| Enumeration Date | 2017-03-28 |
| Last Update Date | 2021-01-01 |