| NPI | 1134671290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1098) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 19902) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14316-I) | |
| Enumeration Date | 2016-10-25 |
| Last Update Date | 2018-10-15 |