| NPI | 1174975734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 89869) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208600000X Surgery (Licence: GA 89869) | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2022-12-08 |