| NPI | 1073197885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116041965) |
| Additional Taxonomies | 208D00000X General Practice (Licence: SC do87837) |
| Enumeration Date | 2021-05-07 |
| Last Update Date | 2026-06-02 |