| NPI | 1366042319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22105) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15107i) |
| Enumeration Date | 2020-10-29 |
| Last Update Date | 2021-06-10 |