| NPI | 1255992426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: DE C7-0017706) |
| 208D00000X General Practice (Licence: NJ C7-0017706) | |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2025-04-06 |