| NPI | 1548756018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MO 2017030854) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2017030854) |
| Enumeration Date | 2018-07-07 |
| Last Update Date | 2018-07-09 |