| NPI | 1093208647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: OH 35.146117) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 72815-20) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 7468851) | |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2023-02-02 |