| NPI | 1982355962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL 1708) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 24203) |
| Enumeration Date | 2022-01-12 |
| Last Update Date | 2025-03-11 |