| NPI | 1740637073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ACN1021) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 19456) |
| Enumeration Date | 2016-05-17 |
| Last Update Date | 2019-01-22 |