| NPI | 1114751104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 24524) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 17137-i) |
| Enumeration Date | 2024-08-30 |
| Last Update Date | 2025-12-15 |