| NPI | 1972037760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL 24250) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 302-P.A.) |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2019-09-20 |