| NPI | 1780415075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center Primary Care (Licence: PR 24598) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 24598) |
| Enumeration Date | 2024-08-09 |
| Last Update Date | 2025-07-28 |