| NPI | 1013604685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10094737) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 330977) |
| Enumeration Date | 2023-04-24 |
| Last Update Date | 2025-06-27 |