| NPI | 1629150487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX G2565) |
| Additional Taxonomies | 171W00000X Contractor (Licence: TX G2565) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2015-08-18 |