| NPI | 1699663971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL 9120407) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9120407) |
| Enumeration Date | 2025-06-25 |
| Last Update Date | 2025-11-10 |