| NPI | 1457924003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1381) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: PR 22450) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2026-07-17 |