| NPI | 1558663203 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PR 18096) | 
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 18096) | 
| Enumeration Date | 2010-12-01 | 
| Last Update Date | 2025-07-24 |