| NPI | 1205179751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: ID M-14547) |
| Additional Taxonomies | 208D00000X General Practice (Licence: GA TM190) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-03 |
| Last Update Date | 2022-08-22 |