| NPI | 1174594980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NC NC2003-00091) |
| Additional Taxonomies | 208D00000X General Practice (Licence: SC 15313) |
| Enumeration Date | 2006-01-30 |
| Last Update Date | 2007-10-23 |