| NPI | 1689793093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WA MD60812507) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 161776) |
| 208D00000X General Practice (Licence: WA 60812507) | |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2022-12-21 |