| NPI | 1760737654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: WA MD00011381) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 27531) |
| 208D00000X General Practice (Licence: MO 29548) | |
| Enumeration Date | 2012-07-17 |
| Last Update Date | 2012-07-17 |