| NPI | 1891792974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 208D00000X General Practice (Licence: AZ 0970) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 32357) |
| Enumeration Date | 2005-07-05 |
| Last Update Date | 2007-07-08 |