| NPI | 1164651212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA A125901) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2009018412) |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2016-03-09 |