| NPI | 1174580856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 15565) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other (Licence: PR Z022) |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2013-04-02 |