| NPI | 1104168269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: WI 62680-20) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 62680-20) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-26 |
| Last Update Date | 2014-09-08 |