| NPI | 1174910251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: PR 21944) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 32676) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-16 |
| Last Update Date | 2020-10-06 |