| NPI | 1174993174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 4301108674) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5315073293) |
| Enumeration Date | 2015-10-02 |
| Last Update Date | 2018-07-26 |