| NPI | 1811454812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 21464) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 14878I) |
| Enumeration Date | 2019-02-26 |
| Last Update Date | 2021-04-01 |