| NPI | 1750909495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 24006) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 24006) |
| Enumeration Date | 2020-07-09 |
| Last Update Date | 2025-03-26 |