| NPI | 1871809442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX S4342) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 4301105543) |
| Enumeration Date | 2010-08-20 |
| Last Update Date | 2023-03-08 |