| NPI | 1710657085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23090) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 16035-I) |
| 363A00000X Physician Assistant (Licence: PR 240-P.A.) | |
| Enumeration Date | 2021-09-17 |
| Last Update Date | 2023-02-16 |