| NPI | 1003505553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MA 1026689) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: AZ R80178) |
| Enumeration Date | 2023-05-02 |
| Last Update Date | 2026-06-06 |