| NPI | 1972160232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME175145) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 22610) |
| Enumeration Date | 2019-05-22 |
| Last Update Date | 2026-01-03 |