| NPI | 1699104539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 20A 3835) |
| Additional Taxonomies | 208D00000X General Practice (Licence: AZ 799) |
| Enumeration Date | 2013-11-01 |
| Last Update Date | 2013-11-01 |