| NPI | 1306928999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: AL 23218) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: AL 23218) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2015-09-09 |