| NPI | 1235344979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 10036) |
| Additional Taxonomies | 305S00000X Point of Service (Licence: PR 10036) |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2019-07-05 |