| NPI | 1619521051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101268945) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101268945) |
| 208D00000X General Practice (Licence: PR 21490) | |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2022-03-08 |