| NPI | 1730814021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22954) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15792-I) |
| Enumeration Date | 2022-07-20 |
| Last Update Date | 2022-10-21 |