| NPI | 1093172926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA 17802) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0102204987) |
| 208D00000X General Practice (Licence: CA 17802) | |
| 208D00000X General Practice (Licence: VA 0102204987) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 17802) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0102204987) | |
| Enumeration Date | 2016-01-22 |
| Last Update Date | 2025-08-01 |