| NPI | 1083271357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23236) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15058-I) |
| Enumeration Date | 2019-05-22 |
| Last Update Date | 2023-07-14 |