| NPI | 1154874121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PR 21177) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 21177) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14091I) | |
| Enumeration Date | 2016-07-26 |
| Last Update Date | 2023-08-25 |