| NPI | 1164072195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22989) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15872-I) |
| 363A00000X Physician Assistant (Licence: PR 000407) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-09-11 |
| Last Update Date | 2022-09-01 |