| NPI | 1942513734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 20A13605) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101018790) |
| Enumeration Date | 2010-07-21 |
| Last Update Date | 2019-11-15 |