| NPI | 1205548773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23992) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 23992) |
| Enumeration Date | 2022-12-15 |
| Last Update Date | 2026-03-23 |