| NPI | 1205579117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 20A20965) |
| Additional Taxonomies | 208VP0000X (Licence: CA 20A20965) |
| Enumeration Date | 2022-04-18 |
| Last Update Date | 2026-07-13 |