| NPI | 1013470988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 313312) |
| Enumeration Date | 2019-04-09 |
| Last Update Date | 2022-01-03 |