| NPI | 1962098749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1361) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MT MED-PHYS-REG-0002152) |
| 208D00000X General Practice (Licence: FL TPME1150) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL TPPA107) | |
| Enumeration Date | 2020-12-16 |
| Last Update Date | 2023-09-13 |