| NPI | 1265171771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 37478) |
| Additional Taxonomies | 208600000X Surgery (Licence: PR 37478) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-06-02 |
| Last Update Date | 2025-10-19 |