| NPI | 1659706935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA 60654646) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 18578) |
| Enumeration Date | 2013-09-05 |
| Last Update Date | 2016-08-05 |