| NPI | 1962552349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 9539) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: PR 9539) |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2013-03-12 |