| NPI | 1164045027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL 208D00000X) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 290-PA) |
| Enumeration Date | 2020-05-26 |
| Last Update Date | 2024-11-04 |