| NPI | 1760159776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22524) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 1054PA) |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2021-08-27 |