| NPI | 1225892938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 24237) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 16758-I) |
| 363A00000X Physician Assistant (Licence: PR 1379-PA) | |
| Enumeration Date | 2024-02-13 |
| Last Update Date | 2025-09-29 |