| NPI | 1104495969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP61518185) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA OL61178996) |
| Enumeration Date | 2021-06-24 |
| Last Update Date | 2024-08-05 |