| NPI | 1740805191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 21904) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15108-I) |
| Enumeration Date | 2020-06-11 |
| Last Update Date | 2021-11-18 |