| NPI | 1063035194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23454) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 23454) |
| 207R00000X Internal Medicine (Licence: PR 23454) | |
| Enumeration Date | 2020-05-23 |
| Last Update Date | 2026-06-30 |