| NPI | 1710551569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22523) |
| Additional Taxonomies | 261QP2300X Clinic/Center Primary Care (Licence: PR 15419I) |
| Enumeration Date | 2021-05-17 |
| Last Update Date | 2021-08-23 |