| NPI | 1316439326 |
|---|---|
| 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: NY 311753) |
| Enumeration Date | 2018-06-05 |
| Last Update Date | 2021-08-04 |