| NPI | 1063920585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23107) |
| Additional Taxonomies | 101Y00000X Counselor |
| 251V00000X Voluntary or Charitable | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15974i) | |
| Enumeration Date | 2018-01-18 |
| Last Update Date | 2023-02-08 |