| NPI | 1376288936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 192878) |
| Additional Taxonomies | 208D00000X General Practice (Licence: AZ 78290) |
| Enumeration Date | 2022-04-28 |
| Last Update Date | 2026-02-16 |