| NPI | 1346801941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0102209401) |
| Additional Taxonomies | 208D00000X General Practice (Licence: ID O-1422) |
| Enumeration Date | 2019-06-25 |
| Last Update Date | 2025-07-02 |