| NPI | 1780415075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1749) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 24598) |
| 261QP2300X Clinic/Center, Primary Care (Licence: PR 24598) | |
| Enumeration Date | 2024-08-09 |
| Last Update Date | 2026-06-03 |