| NPI | 1245882711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22308) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 34-594) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2023-04-16 |