| NPI | 1225385891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MN 55562) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: DC MD038224) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2015-09-22 |