| NPI | 1164982633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 374700000X Technician (Licence: WA 60383237) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA CM60383237) |
| Enumeration Date | 2019-03-21 |
| Last Update Date | 2019-08-19 |