| NPI | 1285941310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: UT 8683129-1204) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101019018) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2025-04-07 |