| NPI | 1447313762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: WV 26005) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 4301088927) |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2016-01-07 |