| NPI | 1083295869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: HI 22964) | |
| Enumeration Date | 2021-04-14 |
| Last Update Date | 2025-07-02 |