| NPI | 1629053236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: AZ 18430) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CO 40573) |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2010-01-22 |