| NPI | 1649505579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MN 38791) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 61683-20) |
| 208D00000X General Practice (Licence: ND 15903) | |
| Enumeration Date | 2009-10-09 |
| Last Update Date | 2025-07-31 |