| NPI | 1306409784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1367) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 21496) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14661-I) | |
| Enumeration Date | 2019-04-21 |
| Last Update Date | 2025-02-05 |