| NPI | 1235824368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 35.152560) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OH 35.152560) |
| Enumeration Date | 2023-04-05 |
| Last Update Date | 2025-08-17 |