| NPI | 1962005637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23080) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15460I) |
| Enumeration Date | 2020-11-17 |
| Last Update Date | 2023-03-29 |