| NPI | 1346295698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NC 2011-01840) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WV 19806) |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2012-02-09 |