| NPI | 1023515194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 21147) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14620-I) |
| Enumeration Date | 2018-04-06 |
| Last Update Date | 2018-11-05 |