| NPI | 1164823886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22132) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR xxtemp) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-09-12 |
| Last Update Date | 2021-06-14 |