| NPI | 1205098654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 4301097627) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX Bp1-0031849) |
| Enumeration Date | 2008-06-26 |
| Last Update Date | 2016-07-14 |