| NPI | 1306425855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA MD.MD.70012646) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 023380) |
| Enumeration Date | 2021-04-02 |
| Last Update Date | 2025-08-13 |