| NPI | 1750807251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 019762) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: PR 019762) |
| Enumeration Date | 2017-08-16 |
| Last Update Date | 2018-12-08 |