| NPI | 1205451101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 94447) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: GA 12026) |
| Enumeration Date | 2020-06-16 |
| Last Update Date | 2026-06-09 |