| NPI | 1811197809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 12713) |
| Additional Taxonomies | 261QP2400X Clinic/Center Prison Health (Licence: PR 12713) |
| Enumeration Date | 2007-07-19 |
| Last Update Date | 2015-07-02 |