| NPI | 1710597885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 022633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 047) |
| Enumeration Date | 2020-08-04 |
| Last Update Date | 2022-03-01 |