| NPI | 1790305811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085N0700X (Licence: UT 14206835-1205) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101273964) |
| Enumeration Date | 2020-04-18 |
| Last Update Date | 2025-03-10 |