| NPI | 1962010546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 538) |
| Enumeration Date | 2020-07-20 |
| Last Update Date | 2024-06-17 |