| NPI | 1710755780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MO 2023028530) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2023028530) |
| Enumeration Date | 2023-12-19 |
| Last Update Date | 2024-05-06 |