| NPI | 1073073417 |
|---|---|
| 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: MI 4301507430) |
| Enumeration Date | 2019-03-21 |
| Last Update Date | 2022-07-21 |