| NPI | 1104403328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX V6874) |
| Enumeration Date | 2021-03-24 |
| Last Update Date | 2025-05-08 |